GW1--05323_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Michael B. Moseley 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft4356 ft.fL ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welb)OR LINER(Bap plicable)
Summit Design and Engineering, Inc. FROM _TO DIAMETER THICKNESS I MA-FERIAE
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ['Municipal/Public 20.1 ft• 35.1 ft• 2 in* 0.010" PVC
Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ft. - ft in.
industrial/Commercial ['Residential Water Supply(shared)
I&GROUT
Irrigation FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 18.1 ft• Ce
PP Y cement-bentonite groin
x Monitoring ['Recovery ft. ft.
Injection Well: ft. ft. -
Aquifer Recharge ['Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer Test ['Stormwater Drainage 18.1 ft• 35.1 ft• No.2 Sand
Experimental Technology ['Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ['Other(explain under#2 I Remarks) - FROM TO DESCRIPTION(color,hardness,soil/rock type,grain Size etc.)
ft. ft.
4.Date Well(s)Completed:7/31/23 Well IU#B-50S ft. ft. T -
t
- I.
5a.Well Location: R. rt. Lr "'�f I��..i
A-1 Sandrock ft. ft. SEF' 0 b 2024
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2091 Bishop Road, Greensboro 27406 ft. ft. info,77-.8:4,:f a ram•,-,-,;, .,2 u
fa
OWCeSOG
Physical Address,City,and Zip ft. ft.
Guilford 21.REMARKS
County Parcel Identification No.(PIN) Well Pad and Cover Inri-ailed
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if wellfield,one Iat/long is sufficient) 22.Certification:
35.987546 N -79.844638 W
x['Temporary Signature o erti Well Contractor Date
6.Is(are)the well(s)lPermanent or
By signing this form,i hereby certifi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or x['No with I5A NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under::2/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35.1 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200 and 2@100') construction to the following:
10.Static water level below topof casing:22.6 ft
( ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:3.25 (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
auger er above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water SuDDIv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016